The nursing assessment helps to detect the patient's current and future care needs through recognizing the abnormal and the normal body physiology (Toney-Butler & Unison-Pace, 2019). The ability to recognize the changes in an individual allows the nurse to prioritize the best interventions for a particular case. The 21-year old case study interview and assessment show the process of detecting normal and abnormal physiology thus, providing the best interventions.
Data and information gathered using the client’s information incorporates her physiological, sociological, psychological, and spiritual needs (Toney-Butler & Unison-Pace, 2019).
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The 21-year old lacks rational thinking because she rummages through trash to collect items she can sell to buy cigarettes, food, and snacks (Toney-Butler & Unison-Pace, 2019).
averages one meal a day
Substance abuse; a) street drugs, once in a while
b) An active cigarettes smoker, using almost two packets in a day
Social support which enables the drug use habit
Lacks a stable income
Shows signs of helplessness by admitting the problem in her life though she has no means of implementing change (Toney-Butler and Unison-Pace, 2019)
Questions employed in the mind during the process of interviewing the client are deliberate and aim to understand the health state and factors likely to affect the wellbeing of the client ( Schultz & Salazar, 1996).
What are the provocative of the energy loss in the body? What exacerbates or improves the condition? Does the activity make the problem worse? What was the client doing when the complaint started?
Quantity and quality of symptoms, is it constant, intermittent?
The region of the symptoms: Is the point of weakness one area of the body or travels around the whole body? As the weakness always existed in a particular area or did it originate in another area?
The symptoms severity: Is the problem affecting the daily living of the 25-year old such her eating, waking, or sleeping?
For how long have the symptoms been persistent: Is the condition better after eating, does it change after smoking or indulging in street drugs, or does it change with the time of the day?
Thus, applying the PQRST tool in this case study evaluates the client’s energy loss complaint thus, enabling a formulation of the right diagnosis (Toney-Butler & Unison-Pace, 2019)
Engaging in a communication that is non-discriminatory and participating in active listening can help gather all the necessary data to assist in planning for the best intervention for the 25-year old client (Public Health England (PHE), 2017). The psychosocial intervention is necessary during the planning process to detect any existing common mental health issues such as depression and anxiety (PHE, 2017). Through the application of the motivational approaches of interviewing, assessment on the family of the client is possible to help in establishing the best treatment approach. According to PHE (2017) psychological management of the health problem is necessary during planning as one can train the client in solving the problems related to their health, approaches to self-monitor the progress in receiving treatment, and develop a strategy that can help with coping enhancement.
A potential strategy to assist the client with the physical problem includes, body mass index advice to help with the nutrition issue of the client thus, help with the reduction of cost pressures in the future related to her eating (PHE, 2017). Brief advice to the client concerning smoking to reduce harm as well as accessing therapies to replace nicotine is vital (PHE, 2017). More so, advice on behavioral support is necessary especially as stopping smoking might be challenging especially because of the existing client's friends that enable her substance abuse behavior. Most importantly, onward referral to a secondary care specialist to help with the substance abuse problem is necessary.
References
Public Health England. (2017). The Role of Nurses in Alcohol and Drug Treatment Services. A resource for commissioners, providers, and clinicians. Royal College of Nursing https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/652963
Schultz, P. R., & Salazar, M. K. (1996). Nursing, health, & the environment: Strengthening the relationship to improve the public's health. Image-the Journal of Nursing Scholarship , 28 (1). https://www.ncbi.nlm.nih.gov/books/NBK232401/
Toney-Butler, T. J., & Unison-Pace, W. J. (2019). Nursing Admission Assessment and Examination. https://www.ncbi.nlm.nih.gov/books/NBK493211/
